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                   Notice of Privacy Practices/Protected Health Information ("PHI")

                                                                                                               (Rev. 12/2014)  

PURPOSE Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical, mental health or condition and/or related health care services is referred to as Protected Health Information (“PHI”). This Notice of Private Practices describes how we may use and disclose your PHI in accordance with applicable law including the Health Insurance Portability and Accountability Act ("HIPPA") and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice the legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of a revised Notice of Privacy Practices upon your request, sending a copy to you in the mail upon written request or providing one to you at your next appointment.  

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU 

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant, only with your authorization. We may also contact you to remind you of your/your child's appointments or to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you. Each time you visit Corri Ferdman, LCSW, LLC a record of your visit is made. Typically, records may contain your symptoms, observations made, statements you have reported, diagnoses, treatment, homework assignments and/or a plan for future care or treatment.  

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.  

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. 

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.  

Without Authorization. Following is a list of categories of uses and disclosures permitted by HIPPA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPPA.         

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.                                              

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order administration order or similar process. ·        

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law or to a family member that was involved in your care or payment for care prior to death based on your prior consent. A release of information regarding the deceased patients may be limited to an executor of administrator of a deceased person’s estate or the person identified as next-of-kin.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel, only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.           

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.    

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party pars based on your prior consent) and peer review organizations performing utilization and quality control.            

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person in connection with a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency or in connection with a crime on the premises.  

Specialized Government Functions. We may review requests from the U.S. military command authorities if you have served as a member of the armed forces authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.        

Public Health. If required, we may use or disclose our PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability or if directed by a public health authority, to a government agency that is collaborating with that public health authority.           

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.      

Research. PHI may only be disclosed after a special approval process or with your authorization. 

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive. ·        

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.           

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.                      

YOUR RIGHTS REGARDING YOUR PHI  

You have the following rights regarding your PHI we maintain about you. To exercise these rights, please submit your request in writing to Corri Ferdman 900 North Shore Drive, Suite 106 Lake Bluff, IL 60044.         

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request and electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.          

Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact Corri Ferdman if you have any questions.           

Right to an Accounting of Disclosures. You have the right to request an accounting of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.         

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.          

Right to Request Confidential Communication. You have a right to request that we communicate with you about medical matters in a certain way or at a certain location. We may require information regarding how payment will be handled.  

Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.         

Right of a Copy of this Notice. You have a right to a copy of this notice.  

NOTE: Records will be kept a minimum of 7 years and possibly longer if you are a minor. Records will be destroyed by using a shredding machine and/or in a fire place/pit.  

COMPLAINTS If you have any questions or believe we have violated your privacy rights, you have a right to file a complaint and we ask that you first do so by calling the office to speak with Mimi at (847) 793-0788. If you feel the issue was not resolved please contact Corri at (847) 302-7778. You can also put your concerns in writing and send it to Corri Ferdman at 900 North Shore Drive, Suite 106 Lake Bluff, IL 60044 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington D.C. 20201, or by calling 202-619-0257. The office will not retaliate against you for filing a complaint.   

Receipt and Acknowledgment ofHIPAA Notice of Patients Privacy Practices I/We understand my rights pertaining to this notice of privacy practices/protected health information (PHI) and agree to my responsibilities as a patient receiving services from Corri Ferdman LCSW, LLC. I/We acknowledge that I/We have been given an opportunity to read a copy of Corri Ferdman, LCSW, LLC’s Notice of Privacy Practices. I/We also acknowledge that I have been offered and declined and/or am in receipt of Corri Ferdman, LCSW, LLC privacy practice notice. I may request an additional copy of the privacy practice notice at any time.  

Patient Signature ___________________________________________________     Date__________________

Parent Signature if patient is under 18 _______________________________________________________ 

Date____________

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